Contact

**We look forward to meeting you and your horses!**
**Call/Text: (626) 250-1218**
**Email: KatyGEquine@gmail.com**
Please call or text to book an appointment. Dr. Glenn-Blea tries to group her calls according to location and will return your call/text promptly. Thank you.

New Client Form

Please take the time to fill out this form, so that we may better serve you and your horse at the time of your appointment. We sincerely appreciate your time and efforts to help us assist you and your horse!

New Client Form

Name

First Name

Last Name

Phone

(###)

###

####

Billing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Trainer/Agent Name

First Name

Last Name

Trainer Email Address

Primary Veterinarian Name*

Clients are required to have a valid Veterinarian-Client-Patient Relationship (VCPR) with their primary care veterinarian; this means that an exam must have been performed by your primary care veterinarian within the last 12 months.

First Name

Last Name

Primary Veterinarian Phone Number

(###)

###

####

Primary Veterinarian Email

Patient Name

Patient Age

Patient Gender

Patient Breed

Patient Color and Description

Patient Profession

Please note if your horse is actively competing and what level of competition, if mainly a pleasure horse, breeding animal etc.

Equine Insurance

Is your horse insured?

Yes

Patient Concern

What is the main reason for your horse's appointment?

Patient Location

Please fill in where your horse resides, if different from billing address. Please include barn name, if it is a multi-barn facility and if there are any gate codes or additional information needed. Thank you!

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

How did you hear about us? If you were referred, please let us know so we can say thank you!

Select Payment Option

Please note that payment is due at the time of service. Cash, personal check, and credit card are accepted. If paying by credit card, please see description below for authorization of credit card payment.

Credit Card Payment Authorization

PLEASE NOTE - credit cards will be taken at the time of service and stored securely on the Square online encrypted server.

By checking this box, you authorize Katy G Equine to charge the credit card provided for services rendered at the time of service.

Contact

We look forward to meeting you and your horses!

New Client Form